TAKING A HISTORY

How to take a complete eye history

Moureen Taking a good history not only helps you to make a diagnosis, it can also help you Takusewanya Ophthalmologist: to understand the impact Mbarara Hospital, Uganda. of the condition on the patient and identify any obstacles to treatment.

t is impossible to over-emphasise the importance of taking a careful Ihistory when assessing an eye patient. Taking a good history can help to focus your examination and indicate what investigations are needed. It can also help you to understand the impact of the condition on the patient and pinpoint any difficulties they may ADRIANE OHANESIAN/SIGHTSAVERS have adhering to treatment. Make careful notes when you take a history. SOUTH SUDAN This is also your opportunity to focus on the patient as a person and to form a relationship of Personal and demographic data trust, respect and mutual understanding. Ask the patient’s personal details: • Name, for identification, filing and patient follow-up How to structure history taking • Address and mobile phone number, for follow-up To ensure you don’t miss anything important, structure and to identify patients from areas with endemic your history taking carefully. Ask about: diseases • Personal and demographic data • Age and gender, for noting Tip: You can use • Reason for visit or presenting complaint down and ruling out any Recording the age, this bulleted list as a gender, language • History of presenting complaint diseases associated with checklist Copy and different age groups and/or sex and disability status keep it where you • Past eye history of patients allows can see it during • General medical history • Language you to monitor who history taking to • Family eye history • Disability is, and is not, help you to stay on • Patient’s occupation, daily tasks coming to your eye track and ensure • Medication history and hobbies. clinic or hospital. that you will not • Allergy history Compare these miss anything • Social history Understanding a patient’s figures with the important. population to occupation, daily tasks (e.g., Each of these is discussed in more detail below. identify groups that looking after grandchildren) and are under- hobbies is helpful for finding represented, e.g., Top tips for taking a good history out a patient’s visual needs girls with other and understanding any eye disabilities, and • Introduce yourself to the patient – this creates a friendly environment. plan ways to reach manifestations or symptoms as a out to them. • Respect the patient’s privacy and confidentiality while taking the history result of occupational hazards. • Ask questions that are direct, simple and clear. Avoid using medical terms and explain things in ordinary language as much as possible. Reason for visit/Presenting complaint • Be a good listener. Avoid interrupting or rushing the patient. Show Ask the main reason why the patient has come to seek them that you are listening and paying attention: make eye contact an eye examination. as appropriate and ask if you are not sure about something they Record the main presenting symptoms in the patient’s said. It is often useful to use open questions (e.g., how are you?) and own words and in a chronological order. The four main closed questions (e.g., yes/no answers) to help focus the discussion. groups of symptoms are: • Try to see things from the patient’s point of view and make an effort to understand them and their circumstances, especially when these 1 Red, sore, painful eye or eyes (including injury to are very different from your own. the eye) • Be aware that patients who are older, or who have disabilities 2 Decreased distance vision in one or both eyes, (including hearing impairment, speech difficulties or a learning whether suddenly or gradually disability) may need a bit more time or may struggle to express 3 A reduced ability to read small print or see near themselves. This may cause them some anxiety, so remain patient objects after the age of 40 years and reassure them that you are there to listen. 4 Any other specific eye symptom, such as double vision, swelling of an eyelid, watering or squint.

44 COMMUNITY EYE HEALTH JOURNAL | VOLUME 32 | NUMBER 107 | 2019 History of presenting complaint Family eye history Figure 1 Case scenarios This is an elaboration of the presenting complaint It is important to ask the patient whether with different presenting and provides more detail. The patient should be any other member of the family has a similar complaints encouraged to explain their complaint in detail condition or another eye disease. This can help and the person taking history should be a patient to establish familial predisposition of inheritable listener. While taking a history of the presenting ocular disorders like glaucoma, retinoblastoma complaint, it is important to have potential diagnoses or congenital eye diseases, diabetes and in mind. For each complaint, ask about: hypertension. • Onset (sudden or gradual) Medication history Course (how it has progressed) Ask about present and past medications for

• CLARE GILBERT • Duration (how long) both ocular and medical conditions. Don’t A case of age-related • Severity overlook any medications that the patient may cataract (history of gradual • Location (involving one or both eyes) have stopped taking some time ago. Some loss of vision) • Any relevant associated symptoms medications are important in the etiology of • Any similar problems in the past ocular conditions. Previous medical advice and any current • It is also helpful to ask whether the patient has medication. been able to use the medication as prescribed Past eye history (their compliance). If a medication is ineffective, Ask for detail about any previous eye problems you want to know whether the patient is actually using the medication as prescribed, for

History of similar eye complaints in the past. P. VIJAYALAKSHM • example glaucoma medications. This is important in recurrent conditions such as A case of red eye due to herpes simplex keratitis, allergic conjunctivitis, Using your own discretion, it is helpful to find bacterial conjunctivitis uveitis and recurrent corneal erosions out whether access to medication prescribed is a problem. This helps to ascertain whether cost • History of similar complaints in the other eye or other concerns are a potential reason for is important in bilateral conditions such as non-compliance. There could also be practical uveitis, cataract issues, such as difficulty instilling eyedrops or • History of past trauma to the eye may explain forgetting to do so. occurrence of conditions such as cataract and Do not forget to ask in a non-judgmental way

retinal detachment MURRAY MCGAVIN about traditional/herbal medication use. A case of ophthalmia History of eye surgery. It is important to ask • neonatorum (history of Allergies about any ocular surgery in the past such as purulent discharge in a Ask about any allergies to medications or other cataract extraction, muscle surgery, glaucoma, or newborn) retinal surgery substances. • Other symptoms. Ask whether the patient has Social history any other specific eye symptoms. • Smoking (amount, duration and type) • Alcohol (amount, duration and type) General medical history Ask about any current and past medical conditions. Birth and immunisation history These include conditions such as diabetes, For children, the birth history (prematurity) and hypertension, arthiritis, HIV, asthma and eczema. immunisation status can be important.

Letter to When something goes wrong are more difficult to discern. There may be fear that Thank you so much for your courageous coverage acknowledging inadvertent harm could threaten public the editor health programmes that deliver substantial benefits. VOLUME 32 • NUMBER 106 • 2019 of medical error in the most recent issue of the

Community Consequently, as described in a recent article (http:// Eye HealthJournal Community Eye Health Journal. Inadvertent harm in health care settings can be devastating for patients and bit.ly/glob-apol), apology in public health is less often caregivers alike. Not too long ago, when I was trained the norm. We in public health can be inspired and

Being involved in a medical error can be devastating; health workers will need the support of senior colleagues (p. 26). STOCK IMAGE in medicine, disclosure of medical error and apology challenged by the progress made by eye health in

When something goes wrong were discouraged because of the potential for lawsuits. acknowledging unintended harm. in medical care

As health workers, we do everything within our power to ensure that our patients have the best visual and clinical outcomes possible. What should we do if Such an approach disrespected patients and morally David Yorston something goes wrong? Consultant Ophthalmologist: Your remarkable coverage of this topic in the Community ealth care is an inherently dangerous activity. We The guidance emphasises that the explanation and apology Tennent Institute of give people drugs that can be poisonous and use should be delivered by a senior clinician. That person may Ophthalmology, Gartnavel Hospital, Hsharp instruments in their eyes. Sometimes, these not be at fault, but she or he is responsible for the care of Glasgow, Scotland, activities will have harmful consequences. What should the patient. A more senior health worker may also be more UK. we do when someone comes to harm as a result of likely to have the knowledge and experience needed in something we have, or have not, done? order to answer the patient’s questions. harmed caregivers. It was therefore tremendously The UK’s General Medical Council – the body that sets If the apology and explanation is to be delivered by a ethical standards for doctors in the UK – provides senior clinician, the more junior member of the team has guidance1 that emphasises the duty of candour: the duty to inform her or his senior colleague aobut the Eye Health Journal has done us all a great service. the duty to be open and truthful with our patients. error. This can be an uncomfortable moment; therefore, If something goes wrong, we have to tell our patients, senior staff have a duty to encourage a culture of give them a full explanation, and apologise. reporting errors without fear of retribution. Continues overleaf ➤ encouraging to learn that, at least in clinical eye care, COMMUNITY EYE HEALTH JOURNAL | VOLUME 32 | NUMBER 106 | 2019 21 Indeed, this issue can serve as a model for other fields disclosure of error and apology are being practiced in within health care and across global health. Thank hospitals and clinics around the world. A recent account you for so positively advancing the conversation, with in the Huffington Post by a gynaecologisthttp://bit. ( extraordinary clarity and forthrightness. ly/Huff-apology) complements your reporting and highlights the positive impact of disclosing medical error. David Addiss When something goes wrong in public health, or Director: Focus Area for Compassion and Ethics (FACE), global health, offering an apology can be even more Task Force for Global Health, Decatur, USA. difficult. Responsibility is diffuse and causal pathways Web: www.taskforce.org Email: [email protected]

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